A need exists for new approaches to medical consultation, physician referral and continuing medical education. In the United States, health care costs have increased since 1960 at the average annual rate of 11.3%, over three times the rate of inflation, resulting in intense scrutiny of both the costs and quality of health care from private, public and governmental institutions.
One solution has been managed care, a concept that has slowed the rate of growth and, in some instances, actually cut costs through the formation of closed panels of providers who deliver care at a pre-negotiated price utilizing managed and controlled approaches. Under managed care, primary care physicians treat the majority of the patients and serve as gatekeepers to triage to specialists.
As medical and technological knowledge increases, primary care physicians must keep abreast of rapidly changing developments. Unfortunately, much of this new knowledge resides with expensive specialists. Consumers are concerned that their primary care physician is limited in his or her access to such information because of the expense of using the specialist, and the physician gatekeeper is viewed frequently by the public as the one who avoids incurring expenses to the system rather than helping the patient.
Primary care physicians frequently need access to leading specialists in a matter of hours when difficult problems arise. Although consultations with specialists in the HMO's provider network suffice in most instances, the necessary expertise may not always be available “in panel,” thus requiring timely access to an expert outside of the panel.
There is consequently a need for managed, direct access to outside medical consultants. Such access helps avoid inaccurate, incomplete, or uncertain diagnoses which can result in inappropriate or excessive care, as well as the liability and operating costs which result when physicians do not receive the necessary help at an early stage in treatment.
HMOs also have an increasing need to better document the performance of each doctor in order to better understand and influence physician behaviors, to modify treatments to coincide with established patient outcomes, to better disseminate improve methods as they arise. Physicians desire ways of obtaining necessary or useful knowledge in an educational format consistent with how they have been trained during their professional life. By better documentation of the knowledge gained through experience, HMOs can improve patient outcomes and decrease the risk of costly malpractice claims. There is accordingly a need for better procedures for encouraging and documenting the continuing medical education which is gained when primary care physicians consult with specialists having particular expertise.
The varying skill levels and the variety of training and backgrounds of providers further complicates the delivery of quality, lowest, cost care. As provider groups enlarge and become less homogeneous, the physician population in organizations is growing both in size and in diversity of knowledge and experience. As a result, educating physicians and other medical staff so as to ensure standards and “best practice” protocols has become a critical factor to effective delivery of health care services. Moreover, health care administrators also want these “best practice” standards to be followed in order to eliminate unnecessary medical procedures without increasing legal liability or stifling a physician's flexibility to practice medicine. There is accordingly a need to integrate the communication of proven practices and protocols which should be applied to special situations with the process of seeking consultation on those special situations.